Basic Information
| Provider Information | |||||||||
| NPI: | 1689307472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODSON | ||||||||
| FirstName: | MICHELE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 FEDERAL ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191475410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8624328485 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 ROCKLAND RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | LJ-0010409 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | SP025238 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | LJ-0010409 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.